MICHIGAN MEDICINE Regional Alliance for Healthy Schools (RAHS) Welcome Letter - School Based Health Center NOT A MEDICAL RECORD DOCUMENT Dear Student/Parent or Guardian: Regional Alliance for Healthy Schools (RAHS) is a group of unique school-based health centers providing services at some public and community schools in Genesee and Washtenaw counties. The goal of the RAHS School-Based Health Centers is to help improve the health and well-being of students and families. Healthy students are more successful in school. What is the RAHS School-Based Health Center? Our health centers are staffed by physicians, nurse practitioners, social workers and dietitians that are available for your physical and mental health needs. The purpose of this program is to provide quality healthcare in a friendly setting, at a time that is convenient to students and families. The RAHS Health Center is NOT trying to replace your regular source of healthcare. The RAHS Health Center is open and available to ALL youth. What can I do to register? Please fill out the attached forms and return them to your school office or to the RAHS Health Center. The enclosed forms include: Consent Forms Health History Questionnaire We also need a copy of the student’s health insurance card What happens after I register? By completing the enclosed forms, the student may be seen at the RAHS Health Center during the school day for health concerns and will be called down for a brief screening visit to obtain basic health information. If your child is in elementary school, we ask that a parent/guardian be available by phone if you are unable to attend the appointment with your child. The RAHS Health Center will bill your insurance company for services received in our centers. How is private health information shared? Please visit the Michigan Medicine Notice of Privacy Practices website here http://www.med.umich.edu/hipaa/UMHS-NPPenglish.pdf or ask at the RAHS Health Center for a copy of our privacy policy. This notice describes how medical information may be shared. Please review it carefully. Thank you, Pathways to Success Academic Campus Scarlett Middle School Lincoln Middle School 2800 Stone School Rd. Rm. 112 3300 Lorraine, Rm. 204 8744 Whittaker Rd. Rm. 812 Ann Arbor, MI 48104 Ann Arbor, MI 48108 Ypsilanti, MI 48197 Phone: 734 973 9167 Phone: 734 677 2708 Phone: 734 714 9509 Lincoln High School Ypsilanti Community Middle School Ypsilanti Community High School 7425 Willis Rd. Rm. 304 510 Emerick 2095 Packard Rd. Rm. 403 Ypsilanti, MI 48197 Ypsilanti, MI 48198 Ypsilanti, MI 48197 Phone: 734 714 9600 Phone: 734 221 2271 Phone: 734 221 1007 Richfield Public School Academy Kearsley High School Beecher High School 3807 North Center Road 4302 Underhill Drive 6255 Neff Road Flint, MI 48506 Flint, MI 48506 Mt Morris, MI 48458 Phone: 810-285-9815 Phone: 810-591-5330 Phone: 810-591-9333 Carman-Ainsworth High School Armstrong Middle School Pioneer High School 1300 N. Linden Road 6161 Hopkins Road 601 W. Stadium Blvd. Flint, MI 48532 Flint, MI 48506 Ann Arbor, MI 48103 Phone: 810-591-5473 Phone: 810-591-2776 Phone: 734-997-1862 Bishop Elementary School International Academy of Flint 8888 Whittaker Road 2820 Saginaw Street Ypsilanti, MI 48197 Flint, MI 48503 Phone: 734-714-9606 Phone: 810-600-5290 Page 1 of 1 NOT A MEDICAL RECORD DOCUMENT 99-10073 HIM: 12/2019 MICHIGAN MEDICINE Regional Alliance for Healthy Schools (RAHS) Frequently Asked Questions About the General Treatment Consent Form 1. What services does the Regional Alliance for Healthy Schools at Michigan Medicine provide? Physical exams Diagnosis and management of Health education/Risk acute and chronic illnesses/ prevention counseling diseases Individual, group and family Immunizations psychotherapy Dental and vision screenings Crisis intervention Basic laboratory test including Referral for substance abuse urinalysis, glucose, rapid strep treatment (Middle and high test, cholesterol, hemoglobin school students) Venipuncture (blood draws). Referral for resources such as food, shelter, financial issues, transportation. Health education or Activities Group such as Walking Club, Nutrition Education, Anger Management, Asthma Program, Peer Mentoring, Mood and Movement, Youth Advisory Council. Bully Busters, and other groups as determined by need (some programs available to middle and high school students only) 2. Why might the Michigan Medicine use my specimens for research? Medical research is constantly discovering new ways to identify, prevent and treat illness. Michigan Medicine is committed to advancing research so we can provide our patients with the most effective medical care. 3. Is telemedicine a service that RAHS currently offers? No, the Regional Alliance for Healthy Schools does not provide services remotely at this time. Will I be notified in the future if this services becomes available at RAHS? Yes, new programming that involves telemedicine will be communicated if available. 4. Can I consent to only part of this form? Yes, a patient has the right to cross out sections of the consent they do not want to consent to. 5. Can I withdraw my consent or my child’s consent after this form has been signed? Yes, you may withdraw consent for services by writing to the Regional Alliance for Healthy Schools Based Health center at any time. To withdraw from all Michigan Medicine service please mail a letter signed by parent or guardian for minor or the patient for patients 18 and over to: Release of Information Unit University of Michigan Health System 2901 Hubbard Rd., 2722 Ann Arbor, MI 48109-2435, Fax: 734-936-8571 or call 734-936-5490. 99-10238 HIM: 06/19 NOT A MEDICAL RECORD DOCUMENT MICHIGAN MEDICINE MRN: NAME: General Consent for Healthcare Services and BIRTHDATE: Important Patient Information - ADULT CSN: DOS: Notice of Privacy Practices (NPP) Acknowledgement: I hereby acknowledge I have been offered or received the Michigan Medicine Notice of Privacy Practices. General Consent to Receive Health Care Services I want to receive health care services from Michigan Medicine including medical, dental, psychological, nursing and/or other health care. Services may include: Surgeries and procedures Medications Immunizations Tests Telemedicine Services Other treatment necessary for my care I agree that Michigan Medicine can share my information as needed for care or billing and that various departments may contact me. To facilitate my care and medical needs, Michigan Medicine departments may need to provide necessary information about me to other outside healthcare providers. I have a right to discuss my health care with my health care providers at any time. I have the right to agree to or refuse any care. I understand that my health care providers generally will obtain my consent after discussing specific care, therapies and procedures with me. My health care providers will review known risks, expected benefits and alternatives to therapies in those discussions. I may need to give additional consents for invasive procedures and special treatments such as when I receive blood products. I understand that the practice of medicine is uncertain. It is impossible to avoid certain risks and clinical outcomes may be different for each patient. Assignment of Medical Benefits I agree that I will be responsible for my co-payments, deductibles or other charges for medical services not covered or paid by insurance or other third party payers. This is true except in cases where Michigan or federal law, or an agreement between my insurance company and Michigan Medicine does not allow it. I assign all rights and benefits to Michigan Medicine in order to help the process of paying Michigan Medicine for health care services I received. I agree to help Michigan Medicine follow up on these claims. Important Patient Information 1. Michigan Medicine is a Teaching and Research Center. I may receive services from staff and/or trainees chosen and overseen by the teaching staff. Trainees and teachers may read and use my health care records for teaching and research. I agree to donate any excess tissues, specimens or parts of organs that are removed from my body during testing or medical procedures and are not necessary for my diagnosis or treatment. I authorize Michigan Medicine to own, use, retain, preserve, manipulate, analyze or dispose of this excess tissue. Michigan Medicine may use or retransfer these items to any entity for any lawful purpose, including education and research. Furthermore, I understand that it is possible that a treatment or test that I receive may have been developed by my physician and that he/she may financially benefit from royalty payments accruing from the use of such a test or treatment which has previously been properly vetted through regulatory channels in accordance with state and federal law. I understand that I am able to ask my doctor if an invention of his/hers will be used in my care. 2. Human Immunodeficiency Virus (HIV) is the virus that causes AIDS (Acquired Immune Deficiency Syndrome). Under Michigan law, an HIV test may be done on a patient if any health care worker or emergency responder comes in contact with that patient’s blood or other body fluids. Contact may occur under the skin, in an open wound or through the mucous membranes, which are the tissues that line various openings in the body. If this type of contact occurs, I know that my blood can be tested without my consent. If a test is done, I know that I will receive the test results and counseling as needed. Page 1 of 2 VER: A/18 Consent – General Treatment / Assign. 31-10048 Medical Record HIM: 12/18 Of Benefits / NPP / IPI MICHIGAN MEDICINE MRN: NAME: General Consent for Healthcare Services and BIRTHDATE: Important Patient Information - ADULT CSN: DOS: 3. Communication Methods.